2022-23 Home Instruction Application

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Please fill out the form below to request home instruction for the 2022-23 school year. There is no longer a remote learning option and only documented medical situations will be reviewed for possible home instruction.

Student Last Name *

Student First Name *

Student's grade level for the 2022-23 school year *

Grades K, 1 or 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

Parent Last Name *

Parent First Name *

Parent Email Address *

Student Email Address *

Parent Mobile Phone Number (The teacher may need to contact you regarding expectations, progress, etc.) *

Mailing Address *

Check one of the following two options for applying for home instruction: *

Medical reasons in the household (documentation will be required)

An unforeseen circumstance (please explain in writing)

Required

Please briefly explain the option you chose here: *

In anticipation of staffing needs, are there any special services that your child requires? Please note, depending on the nature of your student's needs, remote learning may not be able to service the need(s) virtually to the extent the district would be able to do so in person. *

Speech Therapy

Occupational Therapy

Physical Therapy

Mental Health Counseling

Special Education Services as explained in the student's IEP or 504 Plan

Gifted Student Services as explained in the student's WEP

English Language Learner Services

My child does not need any special services.

Required

Check the box below agreeing that you understand there may be in-person events that you and/or your child may have to attend including but not limited to testing, orientation, and picking up/dropping off supplies including technology repairs. Whenever possible, advanced notice will be given. *

I agree

Required

Check the box below agreeing that you understand there MUST be a meeting administration. You will be contacted to set up the meeting. *

I agree

Required

Check the box below agreeing that you understand students must maintain a 2.5 GPA. If the student falls below the 2.5 GPA, they may be required to return to in-person learning at the start of the second semester. *

I agree

Required

Access to high-speed internet is a requirement for home instruction. How does your family access the internet? If you do not have high-speed Internet currently, please contact 844-K12-OHIO to find out if you can qualify for other options. Once you have high-speed Internet access, please resume filling out this form. *

High-Speed Internet provided by your cable company (ex. Spectrum or MCTV)

DSL provided (ex. Frontier or AT&T home)

Satellite (ex. ViaSat or HughesNet)

Through a cell phone provider (ex. Verizon, TMobile, or Sprint)

Dial-up phone access

May need help obtaining internet

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